JCPSLP Vol 16 Issue 1 2014

What’s the evidence?

The effectiveness of knowledge transfer and exchange interventions for implementing rehabilitation evidence into clinical practice Emma Power

E vidence-based practice (EBP) is highly valued by speech pathologists (Vallino-Napoli & Reilly, 2004) because utilisation of evidence can enhance outcomes for clients and their families (Hubbard, Harris, Kilkenny, Faux, Pollack & Cadilhac, 2012). However, EBP is complex and challenging in practice (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004). Despite the availability of evidence, clients do not always receive best practice based on evidence (Runciman et al., 2012). Clinicians are pivotal to the implementation of evidence into practice but organisational, client and evidence-related factors can make this implementation a challenge (Hoffman, Ireland, Hall-Mills, & Flynn, 2013; O’Conner & Pettigrew, 2009). Therefore, researchers and clinicians are increasingly moving beyond traditional clinician-focused EBP models to approaches that capture the creation, communication and application of the knowledge/evidence across a broader range of contexts (Graham, Logan, Harrison, Straus, Tetroe, & Caswell, 2006). Knowledge transfer and exchange (KTE) is one such approach. Knowledge transfer and exchange Knowledge transfer and exchange (KTE) is known by many terms including knowledge translation (KT) and research utilisation, with “implementation science” being the study of KTE (McKibbon et al., 2010). KTE involves a planned, dynamic, interchange of knowledge between knowledge producers and users, so that research evidence can be implemented into health policy and practice for the benefit of clients and health services (Canadian Institutes of Health Research, 2010). In KTE, “knowledge” is considered to encompass multiple views/sources of information, including, but not limited to, research evidence. Throughout the remainder of the paper, the term “knowledge” may encompass research evidence, but is not a substitute for that term. Traditionally, researchers were considered knowledge “producers” and disseminated (or “pushed”) evidence to clinicians through journal articles and conference presentations. Clinicians were considered knowledge “users” and “pulled” evidence from journals and other sources to answer clinical questions. We understand now that “push and pull” models alone are insufficient for delivering best practice and some reciprocity is required in order to deliver evidence-based public health (Grimshaw, Eccles, Lavis, Hill, & Squires, 2012). KTE emphasises a more collaborative “exchange of knowledge” between a

variety of stakeholders who may produce or use knowledge such as research evidence. These stakeholders may include researchers, clinicians, consumers, managers, and health care policy-makers. Processes involved in KTE are represented in Figure 1 with a dynamic, cyclical theoretical framework called the Knowledge-to-Action Process Framework (Graham et al., 2006). Knowledge creation: Knowledge creation (red funnel) may start from simple research inquiry (e.g., individual research studies), move to synthesised knowledge (e.g., systematic reviews and meta analyses), and finally the development of user-friendly tools (e.g., clinical guidelines/pathways). These latter forms are most useful to end users (e.g., clinicians, policy-makers and consumers). Tailoring of knowledge: Knowledge creation may involve two-way contributions from stakeholders at each stage of the knowledge creation process. Consumers and clinicians may have input into research priorities or clinical guideline developments (see Thomas et al., page 30 in this issue for an example). Researchers may tailor their key messages to stakeholders using a variety of modalities (e.g., a video for consumers). The Action Cycle: The blue cycle suggests a series of eight actions (see Figure 1) required for end users to implement and sustain knowledge use in clinical practice based on 31 planned action theories (Graham, et al., 2006). These include: (i) identifying a problem, such as an evidence– practice gap; (ii) identifying, reviewing (appraising), and selecting knowledge such as research evidence to inform the problem; (iii) adapting the knowledge to the local clinical setting; (iv) assessing barriers (and facilitators) to knowledge use in relation to the evidence itself (e.g., strength), adopters (e.g., clinicians and clients) and the environment (e.g., organisations); (v) selecting, tailoring, and implementing KTE interventions or strategies to help users implement knowledge into practice (e.g., educational sessions); (vi) monitoring the knowledge implementation efforts; (vii) evaluating outcomes of knowledge use (e.g., clinician behaviour, client outcomes and changes at the service/organisational level); and (viii) sustaining use of the knowledge (e.g., maintaining implementation and incorporating new knowledge). The action process is dynamic and iterative, and different stages may be addressed simultaneously and not strictly in the order above. In subsequent sections, this paper will provide a scenario in which KTE interventions or strategies may be

THIS ARTICLE HAS BEEN PEER- REVIEWED KNOWLEDGE TRANSLATION EVIDENCE-BASED PRACTICE REHABILITATION KEYWORDS IMPLEMENTATION KNOWLEDGE TRANSFER AND EXCHANGE (KTE)

Emma Power

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JCPSLP Volume 16, Number 1 2014

Journal of Clinical Practice in Speech-Language Pathology